What are the treatment options for chronic worsening hip pain?

Treatment Options for Chronic Worsening Hip Pain

Begin with plain radiographs (AP pelvis and frog-leg lateral hip views), followed by conservative management with physical therapy and NSAIDs, reserving advanced imaging (MRI) and interventional procedures for cases where initial workup is negative or equivocal. 1, 2

Initial Diagnostic Workup

Plain radiographs are the mandatory first step for any patient presenting with chronic hip pain, regardless of suspected etiology 1. The American College of Radiology rates both X-ray pelvis and X-ray hip as 9/9 (usually appropriate) for initial evaluation 1.

• Obtain both anteroposterior view of the pelvis AND frog-leg lateral view of the symptomatic hip—failing to get both views may miss critical pathology 3, 2
• Radiographs identify common disorders including osteoarthritis, fractures, bone tumors, cam/pincer morphology (femoroacetabular impingement), and acetabular dysplasia 3, 2
• Never proceed directly to advanced imaging without obtaining plain radiographs first 3, 2

First-Line Conservative Treatment

Physical therapy is the first-line treatment for mild-to-moderate symptomatic hip pathology with high-quality evidence and moderate strength recommendation 2.

Pharmacologic Management

• Oral NSAIDs (such as ibuprofen) should be used when not contraindicated with strong recommendation 2, 4
• Oral acetaminophen may be considered as an alternative to NSAIDs 2
• Avoid hyaluronic acid injections and opioids—these have strong evidence against their use 2
• Tramadol has been studied for chronic pain conditions with average daily doses of approximately 250 mg in divided doses, though it is not specifically recommended as first-line for hip pain 5

Advanced Imaging Based on Initial Radiograph Results

When Radiographs Are Negative, Equivocal, or Nondiagnostic

MRI hip without IV contrast is rated 9/9 (usually appropriate) as the next imaging step 1, 3.

• For suspected soft tissue abnormalities (tendonitis, bursitis): MRI hip without contrast (9/9) or ultrasound (7/9) 1, 3
• For suspected labral tear or femoroacetabular impingement: MR arthrography (9/9) is preferred, with CT arthrography (7/9) as an acceptable alternative 1, 3
• For evaluating articular cartilage damage: Both MRI without contrast and MR arthrography are rated 9/9 1
• For suspected pigmented villonodular synovitis or osteochondromatosis: MRI hip without contrast (9/9) 1

When Hip Pain Coexists with Low Back, Pelvic, or Knee Pathology

• MRI hip without IV contrast (9/9) should be performed to exclude hip as the pain source 1, 3
• Consider lumbar spine imaging if clinical suspicion exists for referred pain from spine pathology 3
• Screening for lumbar spine and pelvic pathology is essential, as referred pain is a common source of diagnostic error 2, 6

Interventional Treatment Options

Diagnostic and Therapeutic Injections

Image-guided intra-articular hip injection with anesthetic and corticosteroid is rated 8/9 (usually appropriate) for determining if pain originates from the hip joint, particularly when concurrent pathology exists 3, 2.

• Intra-articular corticosteroid injections provide both diagnostic confirmation and therapeutic benefit with high-quality evidence and moderate strength recommendation 2
• These injections should be performed under imaging guidance (fluoroscopy or ultrasound) 3, 7
• Peripheral nerve blocks of the obturator nerve are experimental/investigational with insufficient evidence 3

Radiofrequency Ablation

• Fluoroscopic-guided radiofrequency ablation of periarticular branches of the hip joint has been reported to provide pain relief up to 36 months 7, 8
• This is an option for patients with contraindications to or refractory pain after conservative management 8

Surgical Considerations

• Total hip arthroplasty is the definitive treatment for end-stage hip osteoarthritis 8
• For femoroacetabular impingement, labral tears, and gluteus medius tendon tears, surgical outcomes are typically good, warranting early referral when these diagnoses are confirmed 6
• Approximately 27% of patients report pain at 6 months post-arthroplasty, with 4% developing severe chronic pain requiring revision 9

Common Diagnostic Pitfalls to Avoid

• Failing to obtain both pelvis and hip radiographic views may miss important pathology 3, 2
• Diagnosing based on imaging alone without clinical correlation is incorrect—imaging findings must match clinical presentation 2
• Missing referred pain from lumbar spine or pelvis is common; always screen these areas 3, 2, 6
• Overlooking extra-articular causes such as greater trochanteric pain syndrome, iliopsoas tendonitis, or piriformis syndrome 7, 6, 10

Treatment Algorithm Summary

1. Obtain plain radiographs (AP pelvis + frog-leg lateral hip) 1, 3, 2
2. Initiate physical therapy and oral NSAIDs (unless contraindicated) 2, 4
3. If radiographs show osteoarthritis: Continue conservative management; consider intra-articular corticosteroid injection 2
4. If radiographs negative/equivocal: Order MRI without contrast (or MR arthrography if labral tear suspected) 1, 3
5. If diagnosis remains unclear: Perform diagnostic image-guided hip injection 3, 2
6. If conservative management fails: Consider radiofrequency ablation or surgical referral based on specific diagnosis 7, 6, 8